WWCIC Interference Report Form

This form is intended for the use of licensed commercial and public safety users of radio communications systems operating in Western Washington. Please provide as much information as possible so we are best able to assist you.

Date (This will become your case number): //

Personal Information:

Name(s)	_______________________________________
Company Name	_______________________________________
Address	_______________________________________
	_______________________________________
Phone Number(s)	_______________________________________
E-mail address	_______________________________________

Information about your System:

Call Sign and License Information	_______________________________________
Frequency being Interfered with	_______________________________________
Location (site name or address)	_______________________________________
Location (coordinates)	_______________________________________
Type of System	_______________________________________
What is system function?	_______________________________________
Is your install. WWCIC compliant?	_______________________________________
Technical Person to Contact	_______________________________________
Phone number(s) for Tech. Contact	_______________________________________

Information about the Interference:

Please provide a detailed description of the interference. Is it continuous or intermittent? Is there any modulation? Is it intelligible and can you understand any of it?

_________________________________________________________________________

What have you and your organization done to find the source?

_________________________________________________________________________

How strong is the interference?	_______________________________________
Can you make out a call sign?	_______________________________________
Is it at a particular time of day?	_______________________________________
Does it depend on the weather?	_______________________________________
Where does it occur?	_______________________________________
Have you kept a time log?	_______________________________________
Have you reported to the FCC?	_______________________________________
Do you have any idea who it is?	_______________________________________
If so have you contacted them?	_______________________________________
If contacted what was the result?	_______________________________________

_________________________________________________________________________

Additional Information:

Is there anything else you can think of that might be helpful?

_________________________________________________________________________

The Western Washington Cooperative Interference Committee is a volunteer non-profit organization. We will make every attempt to assist you but we make no guarantee that we can fix your problem. We will put you in touch with people who may be able to advise or help you; however, you should continue with whatever technical and legal recourses that you have at your disposal. Please feel free to use additional sheets if there is insufficient space on this form. Any additional information such as correspondence, pictures or an interference time log would be helpful. All information will be kept in the strictest possible confidence.

Please mail completed form WWCIC

along with any supporting Attention: Secretary

documentation to: 11410 N.E. 122^nd Way – Suite 312

Kirkland, Wa. 98034

Date (This will become your case number): ____/____/____

Date (This will become your case number): //